Automated Healthcare Claims Processing: EDI 837 File Validation Workflow and Quality Assurance Framework Architecture

Abstract

This article presents a comprehensive framework for automated healthcare claims processing through an EDI file validation workflow and quality assurance architecture designed to address the complex challenges in contemporary healthcare revenue cycle management. The article shows the implementation of metadata-driven validation engines that leverage ANSI X12 standard specifications to ensure compliance with HIPAA requirements while accommodating diverse payer-specific business rules and regulatory mandates. The proposed framework encompasses sophisticated validation mechanisms, including member eligibility verification, service date validity checks, provider credentialing validation, and coding accuracy verification that collectively enhance claim acceptance rates and reduce administrative burden. Through the integration of scalable quality assurance components and dynamic rule processing capabilities, the system enables real-time error detection and proactive compliance issue resolution across multiple healthcare transaction scenarios. The article demonstrates how automated validation frameworks transform traditional manual review processes by implementing intelligent business rule engines that adapt to evolving regulatory requirements and payer specifications, ultimately establishing foundational capabilities for future artificial intelligence integration and machine learning enhancement in healthcare revenue cycle optimization.